EMS Stroke Care in the Fox Valley

Transcription

1 EMS Stroke Care in the Fox Valley MARK D. WESTFALL, D.O., FACEP, FACP MEDICAL DIRECTOR, GOLD CROSS AMBULANCE SERVICE EMERGENCY PHYSICIAN, THEDA CLARK MEDICAL CENTER

2 Objectives Introduce / Review our Regional EMS System Identify the Key Component(s) that EMS Provides Review Local / State Protocols for EMS Stroke Care Identify and Discuss Challenges to Stroke Care as they relate to EMS Identify barriers to and opportunities for stroke care between EMS and hospitals

3 What is Gold Cross Ambulance Service Service area is approximately 1,200 square miles Portions of Outagamie, Winnebago, Waupaca and Calumet counties. Serving approximately 260,000 people and responding to more than 17,000 calls annually. Approximately 200 dispatches for Stroke Symptoms

4 What is Gold Cross Ambulance Service Transport patients to all of the regional hospitals; Theda Clark, Mercy Medical Cntr, Aurora Medical Cntr Oshkosh, St. Elizabeth s Hospital, Appleton Medical Cntr, Calumet Medical Center New London Family Medical Center, Waupaca Riverside Hospital, St. Vincent s Hospital, Bellin Family Health Cntr, St Mary s Hosp. & Aurora Bay Care.

5 Clinical Case Scenario 66 y/o male On the phone when he became aphasic Family member call 911 to check on him EMS on scene within 30 minutes of onset of symptoms Patient is aphasic and without facial droop or motor weakness b/p 186/96 / pulse 92 / resp. rate 18 / blood sugar 134 Next steps???

6 Stroke Chain of Survival

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9 Key Points of GCA Stroke Protocol Routine medical care Apply oxygen at 2 LPM by nasal cannula. Support airway as needed Ascertain time of onset or the last time pt. was thought to be well Obtain cell phone# from witness and/or next-ofkin Obtain Blood Glucose, if approved. If < 60 mg/dl refer to Hypoglycemic Guidelines

10 Key Points of GCA Stroke Protocol Do not delay transport to the closest facility with 24/7 CT and tpa availability (if known) Consider IV/IO TKO, if approved. Notify Receiving hospital of Field Code Stroke if symptoms onset less than 8 hours Prep head and neck by removing all jewelry. Remove necklaces, ear rings, piercings, hairpins, hairclips, etc

11 Cincinnati Pre-hospital Stroke Scale

12 GCA utilizes the Cincinnati Stroke Scale F (Face) FACIAL DROOP: Have patient smile or show teeth. (Look for facial asymmetry) Normal: Both sides of the face move equally or not at all. Abnormal: One side of the patient's face droops or does not move. A (Arm) MOTOR WEAKNESS: Arm drift (Have patient close eyes, extend arms, palms up for 10 seconds; if only leg is involved, have patient hold leg off floor for 5 seconds) Normal: Remain extended equally, drifts equally, or does not move at all. Abnormal: One arm drifts down when compared with the other. S (Speech) Have the patient repeat, You can't teach an old dog new tricks" Normal: Phrase is repeated clearly and correctly. Abnormal: Words are slurred (dysarthria) or abnormal (dysphasia) or none (aphasia).

13 Interfacility Transfer Protocol Document current VS; BP parameters stabilized prior to transport tpa: Verify total dose given or to be infused. Document total tpa dose to be administered, start and stop times; if tubing change required for EMS IV Pump, assure correct dose of tpa is included. Following tpa administration, begin 0.9% NS infusion at existing rate; No other medications may be administered through tpa infusion line Oxygen to maintain SpO2 > 94% Strict NPO, including oral medications Perform and document Prehospital stroke scale (Cincinnati Stroke Scale recommended) q 15 or anytime a change in mentation is noted. Document GCS, pupil exam Head of bed at 30 degrees

14 Interfacility Transfer Protocol BP Guidelines: If SBP > 180 or DBP > 105, or BP management medications started at sending facility: Confirm with Medical Control adjustments Labetalol drip: may increase 1-2mg/min every 10 minutes to max dose of 8mg/min, with a maximum total dose of 300 mg, until SBP<180 and/or DBP<105. If SBP<140 or DBP<80 or HR<60, discontinue infusion and contact medical control for further orders Nicardipine drip: may increase dose by 2.5mg/hour every 5 min to max dose of 15mg/hour until SBP < 180 and DBP < 105. If SBP < 140 or DBP < 80 or HR < 60, discontinue infusion and contact medical control for further orders Other: Discuss with Medical Control and sending facility to assure understanding of all medications to be infused enroute. BP Guidelines: If SBP > 180 or DBP > 105, BP management medications not started at sending facility: Inform Medical Control of Blood Pressure and initiation of Medication Labetalol 10 mg IV x1 over 2 min; If no response after 10 minutes, may repeat x1

15 Interfacility Transfer Protocol Changes in neurological condition: (Develops severe headache, acute hypertension and/or bradycardia, nausea, or vomiting) Discontinue tpa Contact Medical Control for further orders; adjustment in BP medications, antiemetics, or including diversion to closest facility. Monitor VS, prehospital stroke scale neuro exam q 15

16 Interfacility Transfer Protocol Oropharyngeal edema: if signs of angioedema are present: (Note- occurs more commonly in patients taking ACE Inhibitors) Stop tpa Treat according to appropriate protocol for allergic reaction/anaphylaxis Monitor airway; consider intubation if persistent swelling Notify Medical Control and Receiving facility of changes

17 Summary / Key Points Maintain a high index of suspicion of Stroke Obtain a thorough history Check patients blood sugar Perform Cincinnati Pre-hospital stroke scale Hospital Notification of pre-hospital Stroke Patient Barriers / Communication

18 Clinical Case Scenario Case Conclusion 66 y/o male On the phone when he became aphasic Family member call 911 to check on him EMS on scene within 30 minutes of onset of symptoms Patient is aphasic and without facial droop or motor weakness b/p 186/96 / pulse 92 / resp. rate 18 / blood sugar 134 Next steps???

19 Clinical Case Scenario Case Conclusion 66 y/o male Aphasic without facial droop or motor weakness Onset of symptoms within 30 minutes of EMS arrival and 50 minutes to the ED Next steps??? EMS give you the history that the patient had a kidney biopsy 2 days prior in Milwaukee from papers found in the patients home.

20 Questions? CONTACT ME AT

21 Food for Thought Do EMS providers know which hospitals administer tpa? Are there any barriers in transporting patients across county lines? Do EMS providers accompany the patient through to imaging? Are runs entered into WARDS in real time (which hospitals can access) or later? Do hospitals provide feedback to EMS confirming it was a stroke? What examples can you share about EMS and/or ED staff working on stroke performance improvement (like attending stroke team meetings or doing a mock stroke code)?

22 Objectives Introduce / Review our Regional EMS System Identify the Key Component(s) that EMS Provides Review Local / State Protocols for EMS Stroke Care Identify and Discuss Challenges to Stroke Care as they relate to EMS History / Exam / Notification Identify barriers to and opportunities for stroke care between EMS and hospitals